434416303-7-25-2024-07-CC-JSEA-DAHS2Z-20241029133020

Community Care Licensing

COMPLAINT INVESTIGATION REPORT

Facility Number: 434416303
Report Date: 07/25/2024
Date Signed: 07/25/2024 07:05:32 PM

Substantiated

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2024 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20240716131345

FACILITY NAME:	REHOBOTH PRESCHOOL/DAYCARE		FACILITY NUMBER:	434416303
ADMINISTRATOR:	MERAT AYALEW		FACILITY TYPE:	830
ADDRESS:	3275 WILLIAMS ROAD		TELEPHONE:	(408) 603-5251
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	8	CENSUS: 6	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Merat Ayalew		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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9

Children left unsupervised

INVESTIGATION FINDINGS:

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5
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8
9
10
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12
13

Substantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 1 of 4

Control Number 07-CC-20240716131345

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: REHOBOTH PRESCHOOL/DAYCARE	FACILITY NUMBER: 434416303
	VISIT DATE: 07/25/2024

NARRATIVE

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--------------CONTINUATION OF 9099 DATED 07/25/2024 PAGE 1--------------

On 07/25/2024, LPA observed at 9:53AM that there were four infants outside with S-1. There was one infant inside the room with S-2. LPA observed that S-2 walked outside leaving the infant unsupervised in the room. S-2 then walked back inside the room. LPA discussed with Licensee that infants cannot be left unsupervised at any time.

As a result of this inspection, a Type A citation was issued. Exit interview conducted and report was reviewed with Licensee Merat Ayalew. A notice of site visit has been issued and must remain posted for 30 days.

LPA Samantha Yip informed Licensee Merat Ayalew that this report dated 07/18/2024 documents one Type A citation which shall be posted for 30 consecutive days as there is an immediate risk to the health, safety, or personal rights of children in care.

Also, LPA Samantha informed the Licensee to provide a copy of this licensing report dated 07/25/2024 that documents any Type A citation(s) to parents/guardians of all children currently enrolled by the next business day or the next day the children are in care, and to any newly enrolled parents/guardians for 12 months from the date of this report. A signed Acknowledgement of Receipt of Licensing Report (LIC 9224), or other written statement, must be placed in the child's file for verification.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 2 of 4

Control Number 07-CC-20240716131345

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT (Cont)

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

FACILITY NAME: REHOBOTH PRESCHOOL/DAYCARE	FACILITY NUMBER: 434416303
DEFICIENCY INFORMATION FOR THIS PAGE:	VISIT DATE: 07/25/2024

Deficiency Type POC Due Date / Section Number	DEFICIENCIES		PLAN OF CORRECTIONS(POCs)
Type A 07/26/2024 Section Cited CCR 101429(a)(1)	1 2 3 4 5 6 7	Responsibility for Providing Care and Supervision for Infants. Each infant shall be constantly supervised and under direct visual observation and supervision by a staff person at all times. This requirement is not met as evidenced by:	1 2 3 4 5 6 7	By POC 07/25/2024, facility will submit plan on how they will ensure infants are superivsed by a staff person at all time.
	8 9 10 11 12 13 14	Based on observation, there was one infant inside the room. Both staff were outside, which poses an immediate health and safety risk to children in care.	8 9 10 11 12 13 14
	1 2 3 4 5 6 7		1 2 3 4 5 6 7
	1 2 3 4 5 6 7		1 2 3 4 5 6 7

Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

LIC9099 (FAS) - (06/04)

Page: 3 of 4

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

COMPLAINT INVESTIGATION REPORT

CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 2580 N FIRST STREET, STE. 300
SAN JOSE, CA 95131

This is an official report of an unannounced visit/investigation of a complaint received in our office on
07/16/2024 and conducted by Evaluator Samantha Yip

PUBLIC

COMPLAINT CONTROL NUMBER: 07-CC-20240716131345

FACILITY NAME:	REHOBOTH PRESCHOOL/DAYCARE		FACILITY NUMBER:	434416303
ADMINISTRATOR:	MERAT AYALEW		FACILITY TYPE:	830
ADDRESS:	3275 WILLIAMS ROAD		TELEPHONE:	(408) 603-5251
CITY:	SAN JOSE	STATE: CA	ZIP CODE:	95117
CAPACITY:	8	CENSUS: 6	DATE:	07/25/2024
		UNANNOUNCED	TIME BEGAN:	09:34 AM
MET WITH:	Merat Ayalew		TIME COMPLETED:	11:00 AM

ALLEGATION(S):

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5
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7
8
9

Napping equipment is blocking exit
Cribs are not free of all loose objects

INVESTIGATION FINDINGS:

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13

Licensing Program Analyst (LPA) Samantha Yip conducted an unannounced complaint investigation for the above allegation. LPA met with Licensee Merat Ayalew and explained the reason for the inspection.

During the course of this investigaiton, LPA conducted observation. Based on the information obtained, the above allegations are found to be UNSUBSTANTIATED, meaning although, the above allegation may have happened or is valid, there is not a preponderance of evidence to prove the alleged violations did or did not occur.

No defiencies were issued as a result of this investigation. Exit interview conducted and report was reviewed wtih Licensee Merat Ayalew. A notice of site visit has been issued and must remain posted for 30 days.

Unsubstantiated

Estimated Days of Completion:

SUPERVISORS NAME: Joel Segura
LICENSING EVALUATOR NAME: Samantha Yip
LICENSING EVALUATOR SIGNATURE:	DATE: 07/25/2024

I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.

FACILITY REPRESENTATIVE SIGNATURE:

DATE: 07/25/2024

This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC9099 (FAS) - (06/04)

Page: 4 of 4